dr. solomon's dilemma






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martin solomon, m.d.

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Martin Solomon, M.D., has been practicing family medicine in Boston for 23 years. He is consistently named in "Top 10" lists of Boston doctors, and is well known throughout the Boston medical community. In 1998, Dr. Solomon sold his practice to CareGroup, the corporation of six hospitals in Boston, including Beth Israel Deaconess (BID). He currently is the leader of Pod 11, a group of 11 primary care physicians in Brookline trying to manage patient costs and care. He is also the author of Don't Worry Be Healthy, a book which encourages people to enjoy their life more while worrying less about their health.
What does "doctors sharing risk" mean? How did you get into that?

The way managed care works, at least here in Boston, is that the insurance companies take a fee of $500 from a patient. They might keep $100 of it for their administrative fees, and they then set aside $400 to be spent on patient care.

But instead of giving that $400 to the people who deliver the care, they give $400, but they'll hold out an amount--anywhere from ten to 15 percent, say, $40 up to $100--and hold that money in what is called a risk pool.

That risk pool is designed so that there will be enough money to pay any overages if care is delivered that exceeds the $400 cost. It's also is a way of trying to encourage the physicians to behave in a fashion that will keep the cost down, to order fewer tests, because if they use up their money and they lose that risk money . . . they'll end up with thirty-seven and a half cents on the dollar, instead of getting fifty cents on the dollar. . . .

So doctors need to try to keep that money. Otherwise they'll just keep losing money. The risk money that's withheld is money that, theoretically, they're entitled to for providing care. The way that risk money is distributed depends on how well the doctors do in controlling the overall cost of care. If you order a lot of extra tests, if you order very expensive medicines, if you keep your patients in the hospital longer than the insurance people feel is appropriate and exceed the cost that they've decided should be spent, then you start to eat into that risk money.

Which means, in effect, you eat into your salary.

Basically, you eat into your salary. It's not as if you're eating into a bonus. You're eating into money that was supposed to be paid to you in the first place.

Where does the pod fit into this? What's the pod trying to do?

The pod is trying to modify behavior, to try and get doctors to work together to continue to deliver a good quality of care at a lower cost, which clearly can be done. We can write for less expensive medicines that do the same things. We can do a better job in keeping our patients well and keeping them out of the hospital. We can do a better job of rehabilitating our patients after surgery. Most importantly, of course, is trying to keep them well by doing everything right to begin with.

But you're talking about the pod, and it's affecting behavior. It's doctors influencing doctors. Is this peer pressure, or peer education, or is it a combination of the two? What's the dynamic here?

The bulk of the pressure comes from the fact that we all know that there isn't enough money flowing through the system to support the system now. Everybody's salary and contract is on the line, and we've got to do a better job or the system will collapse.

I think of doctors as being pretty individual people, and particularly here in Boston, they're Harvard, highly educated, and very proud of their own professional skills. Is there a tension when doctors start to tell colleagues sitting around in the pod room, "Wait a minute. Maybe you should order those tests." Or, "You should be ordering different drugs, or prescribing different drugs." How does that work?

There's tension between the people who are hearing that there's a problem in the way they're doing things, and the people who are telling them that. That could be coming from the overall organization--the network of hospitals passing down data to us on how we're behaving--or it could come from people like myself, who are the pod managers, who are responsible to disseminate the information to the physicians in the group.

We all know that there isn't enough money flowing through the system to support it.  Everybody's salary and contract is on the line, and we've got to do a better job or the system will collapse. We're trying to get a handle on where the figures are coming from--why some doctors are prescribing most expensive drugs and some aren't; who they are; is it the nature of the patient population they're taking care of, or is it because of their prescribing habits?

So the hospital organization has worked very hard in developing a formula to look at the patient population, and weight them in terms of risk. Some doctors may have patients who are older and sicker. Some may have very young, healthy patients. Some may have more women in them. Some may have fewer women.

All of these affect the way tests are ordered and prescriptions are written. So you have to have a way to look across the board at everybody, and weight everybody's performance in a manner that's equal. The reports that we're getting now are reports that look at as many factors as they can fit into this formula, and try to equate that with what they call "the efficiency index," which is a way of comparing physicians, one to another.

How do the numbers change behavior?

When somebody who heads your organization gives you reports that say you're either doing well or you're not doing well against the benchmark, there's the implication that that person believes you're either doing well or not doing well. Most of us respond to that cue, and recognize it as a sign that we've got to change.

Or we can get angry, but that isn't very effective. Most of us are wise enough to know that it's not effective. If a colleague does it, we can have a long discussion about it, but that might not change behavior as urgently as the director of the group saying, "Look, these are your numbers. Look them over, and we'll talk about them later."

Do you see behavior changing after a meeting like that?

Behavior changes in subtle ways every time you look at the data, because we're all motivated to be the best. Everybody wants to get an A. Everybody wants to be the number one, to have good numbers when they're presented to the group. I'm sure behavior changes.

What are you trying to get the members in your pod to look at?

There are several key areas of utilization that have the greatest impact on our financial picture. One is pharmacy. That's the single largest one. That's across the board, not just in our group, but nationwide. Pharmacy costs are so high that they've actually exceeded our inpatient hospital costs. So we're looking at that very carefully.

We're looking at the length of stay, at how long we keep people in the hospital, whether we keep them in longer or shorter than the benchmark, whether it's appropriate for the diagnosis. We're looking at the number of tests that are ordered, whether they're x-ray tests or other kinds of ancillary tests.

Some tests need to be ordered more, for example, mammography. Theoretically, mammography utilization should be 100%. If you look at most studies, most people are down around 70% or 60%. Some of that is because patients don't go, and some of it is because we just don't do it. Our group just happens to be over 90%. We've done very well.

The last group is out-of-network referrals. That's patients who are referred out of the provider group, which is a very costly part of our thing. Those are the four major elements that we look at when we look at how we're doing in terms of utilization.

I know there are other issues involved, but it feels as though again and again you're coming back to money being the bottom line. This is about money.

Yes. Of course it's about money. Somebody's got to pay the bills. There's tremendous financial tension. The amount of money being lost is really mammoth. The amount of debt that we incur with some of these managed care plans is running now into the millions of dollars. So we know that we're really in a hole, and the numbers are shown to us on a regular basis. Every month, we see how deep in the red we are.

We get a fixed amount of money to pay for patient care, and then we get a certain amount that's added back in at the end of each quarter if we remain under budget. Since we've had a static number of patients coming in over a number of years, we haven't been growing that group.

Since they've started coming in, the patients are getting older and older. When they first came in, their cost was very low. It was very profitable. We had a lot of money left at the end. There was enough to pay all of our bills, and still maintain a reasonable income from it.

But now as the patients are getting older, they're requiring more care, and we're not meeting our budget any more. We're actually spending more for their care than we're getting paid by a capitated plan like Secure Horizons. If we continue this pattern, by the end of this year we'll owe hundreds of thousands of dollars back to Secure Horizons, and that's just from our group of nine physicians. We'll owe hundreds of thousands of dollars back to the insurance company if we can't be more effective in delivering care.

People think of doctors making a pretty good living. What's the dollar and cents implication of what you just said? Will people who are making $150,000 or $200,000 a year now be making $50,000 less? Will people who are making $100,000 a year be making $20,000 less? If that happens for the eight or nine doctors that are sitting around the room, what is the implication of the statement you just made?

If you extrapolated this and it continued in that pattern--which won't happen, because we'll find some way to balance things out--but if we were to continue to lose money like that, doctors won't do this work for $50,000 a year.

What will happen is the practices will close. People will go out of business. If you look at the other hospitals here in the city, one of the major other provider groups in the city has dumped the senior globally capitated plans, because they were losing so much money with them, they felt it would drag the institution down. So instead of trying to find some way to accommodate the elderly patients they were caring for, they just said, "We're won't do it anymore," and they just dumped all the patients.

Too many sick people?

Too many sick people.

You sound like a man wearing two hats. One is the financial hat that says, "Hey, we've got to cut the cost of care," and the other hat is . . . What is this like for you, as a doctor?

It's terrible. The worst experiences I've had in my professional career have been within the past few years dealing with patients on issues of managed care where we're trying to control costs. The only time I've been in arguments with patients and really had very, very verbal arguments with patients about where they should be going for their care has been surrounding the issue of managed care.

It's really been heartbreaking. I try to avoid it as much as I can, because really the only part of medicine that's unpleasant right now is just dealing with this issue--fighting with people about why they can't go to see whoever they want, why they can't go to whatever hospital they want, why they can't have whatever drug they want.

What they don't understand is that we're enforcing these things so that we don't lose more money, because we're losing so much as it is. This is income that we're entitled to because we've earned it, and it's being held back from us by the insurance company. If we allow patients to break all these rules and make special exceptions left and right, then we're actually subsidizing their right to do that with money out of our pockets. I didn't go into medicine to pay for other people's care.

I don't mind giving free care. What I do mind is giving care to people that I'm supposed to be getting paid for that they think I'm getting paid for, when not only am I not getting paid for it, but I'm subsidizing their care to go somewhere else. I just can't do that.

Has your income level actually been going down in recent years?

Until this past year when I joined the group that I'm in, I was actually in private practice. Over the four years before I joined this group, my income dropped every single year by a minimum of 6% and a maximum of 15%. So over a period of about four years, I saw my income drop over 35%. It was just going down every year, and it would have gone down more this year were I still in private practice, because of the way the contract was negotiated this year.

I'm not crying. I'm making very good income. I don't feel that bad about it, and I'm still doing the work I'm doing, but it's not like we're making more and more every year. We're getting pretty well hammered out there.

When you look at the general working of the pod, how long has the pod been going?

I think the system's been set up for about eight or ten months, maybe a year.

What's the best thing the pod has done? If you had to cite the upside of the pod, what do you think it's been able to do well?

We've developed uniformity in the way we deal with a number of medical problems. Everybody has different ways of dealing with different issues. By discussing what is the best care for various problems while considering costs, I think many of us have come to a more uniform way of dealing with a problem. It doesn't mean we've narrowed our options, or are not being creative, or aren't thinking more openly. But some of us might not have been up-to-date in the way we manage things.

That has really revolutionized the way we're treating asthma patients now, and we're doing a better job. They're healthier because of it. That's an effective example of what we've been able to do.

What are the biggest problems?

What's holding us back primarily is the cost of pharmacy. That's the biggest problem. The second biggest problem is the difficulty of keeping people from going to physicians outside of the provider group. Boston is a medically sophisticated city. There isn't a hospital in Boston that's the best. Every hospital in Boston is outstanding, as far as I'm concerned. There are great doctors everywhere, and patients know that. They want to be able to get the person that they think is the best. It's very hard to convince patients to stay within the system.

So why should they stay within the system?

Because that's the way their insurance plan is written.

No, their insurance plan lets them go, doesn't it?

No. It only lets them go if we allow them to go. That's the catch. If they call the insurance company and say, "I want to go to a certain physician that happens to be out of my provider group, but he's a member of your insurance plan," they'll say, "Well, if your primary care physician says it's okay, then it's okay with us."

Why don't you okay it?

The insurance company doesn't care because they don't pay for it--I do. . . . If the patient goes outside of your provider group, that whole amount goes to the other physician.

I get into that argument with patients, and discussions about where they should go for their care, because I know that, at the end of the month, I'll get my report from my pod. If we're not performing well, it'll be because if every doctor in my group allowed somebody to do that once a month, we'd be in the toilet with our budget. We just can't do that.

...

What do the patients say?

One woman said, "You're not letting me do this because of money." My response to that, usually is, "Of course. What do you think it is? If it was just medical care, I'd let you go wherever you want. But this is a contract, and I'm not in the business of subsidizing your care. I'm not here to pay for your medical care. The way the insurance company has structured this, if you go outside of our provider group, I and my colleagues in my pod subsidize your care at the other institution, because you're taking the money that's being withheld from us to pay for your care."

And that's not what we're there for. We're there to take care of you. If we can't take care of you, if we can't give you the care that you need, then it's reasonable to go elsewhere. Quite honestly, every single week this comes up, sometimes, every single day.

How do you feel about that as a doctor?

I hate it. It's the worst thing I'm doing now. I try not to think about it. If I can get through the day without having to do that once, it's a great day.

Do you see your colleagues struggling with the same kind of issue?

Some people struggle with it. Some people don't yet understand the impact of it. There are people in the organization who continue to allow patients to do whatever they want. That hurts them and it hurts all the rest of us. We're trying to get them to understand that. If it means we're going to lose patients to other institutions, then that's what it means.

Do you think it was a mistake to try to take on this risk? It sounds as though what's driving you is this withheld money, this risk money. Is that a smart policy? Is that a smart strategy for doctors?

I don't think it's a good strategy for doctors to be involved in the financial aspect of care at all, except to understand what the costs are in an effort to keep the costs down. Once we are put at risk, you can't deny that it will affect the way you make decisions. I don't care how much you fool yourself. At some level, it has to affect the way you make decisions. We should be making decisions solely based on what's best for the patient.

Do you think that your colleagues understood this when they reached to take some of this risk back from the health plans?

The way it was originally presented to us it looked a lot better. It looked as though there was a lot of money to be made. There were plans involved in globally capitated contracts around the country that were raking in millions of dollars because of the way they were managing their care, and because they had new, young, healthy patients coming into it.

Also when the plans were first set up the federal government was pouring larger amount of money into the Medicare capitated risk programs. . . . Medicare takes its Medicare money and disburses a fixed amount, based on where you are in the country for the care of that patient to the insurance carrier.

So the insurance carrier would get this block of money, keep their amount, and then spread it out. Initially Medicare was pouring too much money into it. There were groups all over the country making millions and millions of dollars. It looked very attractive. So everybody jumped into it. It seemed a great way to make up for some of the other deficits that we had.

Then what happened?

Well, then Medicare cut down on the amount, because they realized they were overpaying. The patients started getting sicker, medical care costs went up, and all of a sudden that great big fat balloon disappeared.

You say you have ethical discussions.

Ethical discussions about whether it's reasonable to tell a patient that they can't go to their oncologist outside of our provider network that they went to for their malignancy, who they've been seeing for the past five years. We've had to do that a lot--tell patients you've got to stay in the system.

So what you're saying really is that choice, which a lot of patients want and what a lot of health plans are selling, is a killer for doctors and hospitals.

Absolutely. Absolutely.

How do you lick that? Choice is the hottest word in the medical market at the moment.

It goes back to a theme that I bring back to patients often, which comes from a song by the Rolling Stones: "You can't always get what you want, but if you try sometime, you might find you'll get what you need."

The system now is set up to give people what they need, not what they want. What they need is good medical care from good doctors who are concerned about their care, and it's taking away what they want, which is choice.

How has the whole context changed in terms of the economic climate and the sense of competitiveness? How has that affected the practice of medicine?

When I went into practice 21 years ago, I had the advantage of being a native of the town, having trained in the town, having gone to medical school here. I knew most of the hospitals in the city. If I had a patient who had a medical problem, I would chose the physician who I thought was the best person to take care of that--not the institution--but the physician, whether they were at the New England Medical Center, the Mass. General, the Deaconess, the Beth Israel, the Brigham. It didn't really matter.

That changed dramatically in the past seven or eight years, as the managed care contracts forced us progressively to try and stay within the system. In the past two to three years, it's become severely restrictive. Now I no longer can utilize care across the city, and the people who work at the other hospitals can also not do the same.

If somebody at the Brigham wanted to use a gastroenterologist at the Beth Israel or the Deaconess, they couldn't do it, because it would negatively impact their budget, and they would end up losing money on it. The truth is there are good doctors all over the cities, so you can justify keeping people within the system for that reason. But what you're doing is removing choice.

The other thing that's happened as a result is that the cross-fertilization that occurred between institutions has stopped. We no longer have physicians who work at both institutions, and patients who are cared for across the board. The collegiality and sharing of information is all gone.

We've gone from the mecca of medicine to a medical Beirut, and it's really a tragedy. I think it's really destroyed medical care here.

You went from a system where you could pick any doctor in any institution anywhere, and now you've got to stay within the team. Can you honestly say that doesn't affect the quality of care, at least in a few cases?

I'm sure it affects the quality of care. I'm certain it affects the quality of care.

Negatively?

Absolutely. First of all, there's duplication of services. We're spending money unnecessarily to do things that we could do at different institutions if we cooperated more. We have more specialists in each hospital because we have to substitute care there that we might be doing at another hospital.

How about from the perspective of the individual patient?

From the perspective of the patient, they may not be getting necessarily the best care. Absolutely.

Because you have to play this team loyalty?

Because you've got to stay within the team. Absolutely. It's not just in our institution. It's in every provider group in the city. It's restricted.

What's your reaction to that? Good system? Bad system?

I think it stinks. I've spoken out about it many times. I think there are ways to fix it, but you need leaders who have the courage to do that.

So you lose money this quarter, and maybe more in the next quarter. At the end of the year, what does that mean?

Well, it means that if we continue to lose money beyond what's coming in, we actually have to give money back to the insurance company.

You write them a check?

We write them a check. We, physicians write checks that go back to the insurance company.

And it comes out of your back pocket?

Out of our pocket. We don't have any reserves.

How do people in your pod, in your group, feel about that right now?

Well, they're anxious and they're upset, because their income is directly impacted. They're going to lose money. Not only will their income drop, but we will individually have to actually pay the money back.

Can you afford to keep going on like this? Are people talking about dropping this bunch of patients?

We can't afford to keep doing that indefinitely like that because, obviously, we have to be able to make enough money to run our practices, too. This can become quite costly.

Can the hospital afford it?

Can they afford it? No. Nobody can afford it. The hospitals can't afford it. The patients can't afford it. Nobody can afford it. That's the problem. Nobody can afford any of this.

So what's going to happen to all these elderly, sick people?

Either the government's going to step in and pay for it, or care is going to be difficult for them to find and they won't be able to get care. It makes it very uncomfortable when a patient calls and asks for something that I don't really think that they particularly need, but I don't think that it would make that much of a difference, and they really want it, and I have to say, no

You have to say no for financial reasons?

I have to say no purely for financial reasons. Or they want to go outside of our system because they've heard of a doctor who they think is better. If I allow them to do that, then I'm going to have another situation like this where not only are we not getting paid, but we're subsidizing the care. The way it works out, there's a fixed amount of money, and we have to use that money to pay for the patient's total care. If we use up that money paying for services, then there's nothing left to pay us. It's gone. We pay for all of the care of the patient, whatever services they receive, and when that money's gone, that's all there is.

And you wind up going in the hole?

We wind up by going in the hole. The hospital has to go into the hole. Everybody goes into the hole.

Is this a pattern throughout this program for seniors that you're talking about?

Well, here's an example, a patient I have in the hospital right now. She's a Secure Horizons patient who I brought into the hospital last Friday, a very ill woman, who we had hoped to have in and out of the hospital to treat a specific problem in two days. It's now seven days later at $1,200 a day. We haven't solved her problem.

I expect she's going to be in a lot longer. I've already lost money on this patient. Anything I do for this patient now is money that is going to be subtracted from us. It's not money that we're not going to get paid. We're actually going to have to pay it back. So this has become a very costly Secure Horizons patient.

Is there a ceiling?

There's a ceiling because we get a fixed amount of money from the insurance company to provide all the care for this patient. This is a globally capitated patient, which means that all of the services that the patient requires come out of the budget of dollars that we receive. Once those dollars are used up, then we start dipping into the pool of the rest of the money that's in there. Now we've got so many elderly, very sick patients, that that pool is vanishing, and there's no money left.

Now you've got a hospital that's in the red. What are the choices? What can you do about that?

In the moral real world, we really don't have a choice. We have to provide the care, but we can't go on doing that forever for everybody. . . . The hospital wouldn't be able to pay their bills.

I think it's hard for a lot of people, Doctor, for people to feel sorry for doctors and money.

Sure.

And you know why. What are doctors making in your pod? If you have to pay the insurance company, how big of a chunk is going to come out of their salary?

The average internist in this country now is earning about $110,000 a year. That's about what our people are earning, plus or minus, depending on the amount of time they're putting in. If they have to write a check back to the insurance company for $5,000 or $10,000, or if their income is dropped by $5,000 or $10,000 because of losing care, and that continues each year, there comes a point to which the doctor will say, "I'm not real comfortable working ten hours a day, taking calls all night long, doing all this work, and not be able to pay my bills."

In fact, somebody said that to me in a staff meeting just last week. I can't pay my bills. Now, sure, these are people who are earning a lot of money, more than most people in the country. But they also have a standard of living that they spend up to what they live. So if they start having less money . . . it's a lot easier to spend more than it is to cut back.

And yet you're being told to run health care like a business.

Well, health care is not a business, as you can see. You're dealing with people whose lives are destroyed and shattered, and you can't turn your back on them. You just can't. We wouldn't want anybody to do it to us.

How do we get out of this bind?

Well, clearly, it's a very conflicting situation. That's why, when you asked before how I felt about this managed care thing, I feel terrible about it. I'm very conflicted in providing the care that I know the patient needs and yet, I know that I'm losing money when I see this patient, and if I have more patients like this, as I do, then I'm losing more and more money. There comes a point at which I can no longer afford to do it, because I can't do anything.

One of the things that we see in the new medicine is a tremendous focus on data, performance data, and report cards. What do you get, as a pod leader, from the higher-ups?

We actually sit down and talk about exactly how many tests we're ordering. If some patient of mine goes to a physician other than me and gets a prescription drug that is not part of our formulary, that comes back to me in a report. I'm the one who's penalized for that, and I get that report in detail, and I know who wrote the prescription, too. That's how detailed the data is.

Here's another report that breaks down costs based on utilization for all the different categories of services provided. So, for example, office visits, inpatient visits, psychiatric visits, home visits, inpatient and outpatient surgery, tests, medications, radiology, emergency room, are all broken down by cost--interestingly, by cost per unit. You notice this is the insurance company term-- not cost per patient, but cost per unit.

They're not people anymore.

No, they're units. And then it breaks down as to what these are costing us per member, per month, against what was budgeted for that care. Let's take office visits. You can see that I was budgeted $18.49 for this period per member, per month, for office visits. $11.81 per member, per month was spent, so my variance against what was expected was actually negative.

Fewer visits than were budgeted. So we sort of made money on that. But let's look at therapies. These are treatments that people are receiving of a complicated nature. . . . You see that I was budgeted $1.59 per member, per month, and I spent $2.63 per member, per month, and that's the way they look at it. I spent it. The patients received the care wherever it was given, but it was coming out of my budget. So I was in negative balance for $1.04 per member, per month. That's a 66 percent override, and that reflects back on me. And so I have to say, "What are these therapies that we're giving?"

Can you be that statistical and that abstract about something as unpredictable as medical care?

I can't. I just deliver the best care I can and hope we do it right, and try and be conscious of all these factors. But you just can't think about it all the time. You can't worry whether the care that you're giving is going to throw these figures off. But, unfortunately, what they're telling us is that we do have to worry about it.

So every time I write a prescription, every time I order a test, every time I send a patient to the emergency room or refer them to another doctor, this is somewhere in the back of my mind. How is that going to look on the figures next month? Even if I don't want it to, I know that next month I'm going to sit down with the other doctors in the group and we're going to look at these figures.

When you're looking at this stuff, what's going through your head when you're treating a patient?

Well, let's talk about a patient here in the office, for example, somebody who came in today with respiratory illness. It wasn't clear whether it was just a simple respiratory illness or something more complicated, and my reaction based on this particular patient was that I was concerned that the patient actually had a pneumonia.

My natural reaction would be to order a chest x-ray and possibly a blood count, and wait and see. Now, as I'm about the write that down, I'm saying to myself, now, how is this going to impact my x-ray utilization this month? I'm ordering another x-ray. I suppose I could just treat the patient and not do the x-ray, but then I'm going to be uncomfortable that I'm really not doing the best job I could.

Some people today would argue that you shouldn't do the x-ray, just treat the patient. And you can tell them that you think it's pneumonia, but maybe it's not. So I sent the patient for a chest x-ray, they came back and had pneumonia, and I treated them. And then I had to pick a drug. I could use our standard formulary drug.

As I'm sitting there writing on the paper, I have to ask the patient, what are you allergic to, and this patient was allergic to the formulary drug. So I prescribed the standard drug we use to treat pneumonia in this patient. But I could've chosen a different drug which would have been much more costly. Part of the reason that I didn't choose that drug was because it was more costly, not just to the patient, but to our pod. Now, they're both equivalent. I could've used either one. As I give the patient that drug, the said to me, "Well, what about this other medication?" because their friend had pneumonia and got the other medication.

And I said, "No, this drug is just fine. It will do the job well." They said they heard that this was a new, really terrific drug that would be much better. The truth is that it wasn't really much better, and it probably wasn't the best drug for this setting, but one could argue for that and the patient was asking for it.

When I said no at that point, it was no longer just because I was giving them the right drug. It was also because if I acquiesced to their request and gave them the drug that they wanted, it would've cost me a lot of money.

Do patients understand the motivations that are driving you?

No, I don't think so. They're suspicious of it. They say to you, "Is this a financial decision? Is this because it costs too much? Is it because my insurance plan won't let you?" And I say to them, "No, it's because this is the right drug." It also turns out that this is a less expensive drug.

Do you always level with patients, or do you sometimes . . .

No. If they ask me, I'll level with them most of the time. I'm sure there are probably times that I don't, but I can't think of any offhand. There are some times when you have to stretch things a little bit, where people are really asking for something that's just off the wall.

You need to reinforce that this is the right thing to do, and make them understand that you're not jeopardizing their health because of the constraints of their insurance plan. Before we talked today, I was on the phone with a patient who we had to switch from Zocor to Lipitor. These are very equivalent drugs. These are cholesterol-lowering drugs. But Lipitor is a lot less expensive. It's at least as effective as Zocor, and a lot less expensive. The reason he was switched was not because it was better drug, but it was because it was less expensive, and he wanted to know why we were doing it.

So I told him, and he got very angry. I told him, "It's the same thing. It will do the same thing for you." He was angry that a decision was made about his care based on the cost of the treatment. I understand his point of view, but the truth of the matter is that there is not an unlimited supply of dollars to pay for this care.

And I said to him, "This is the right medicine for you. It's a good medicine. It will do a terrific job, and this is the one that I want you to have." He wasn't happy about it, but he'll take the medication.

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